Laparoscopic-assisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists' 1995 membership survey.

A questionnaire was mailed to all members of the AAGL to determine the current performance of laparoscopic-assisted vaginal hysterectomy (LAVH), and to assess the relative frequencies of techniques and complications. Answers of the 1092 members who responded were entered into a database computer program and analyzed. The analysis revealed 14,911 LAVHs performed by 767 members. Complication rates appeared to be in the same range as those reported for vaginal hysterectomy and total abdominal hysterectomy. Inferior epigastric injury was the most common complication. Physicians showed a shift in their practices away from abdominal hysterectomy after they learned LAVH.

Reproductive outcome after tubal reversal in women 40 years of age or older.

OBJECTIVE: To determine the reproductive outcome of women who received a microsurgical tubal anastomosis operation at age 40 years or older. DESIGN: Multicenter retrospective cohort study. SETTING: Four university teaching hospitals. PATIENTS: Fifty-two women having undergone tubal sterilization reversal at age > or = 40 years. MAIN OUTCOME MEASURES: Pregnancy and live birth rate. RESULTS: Of the 52 women, 10 were lost to follow-up. Of those traced, 18 of 42 (42.8 percent) conceived. Of those 18, 6 patients had a live birth, 10 patients had a first trimester spontaneous abortion, 1 patient had an ectopic pregnancy, and 1 patient had an elective termination. Overall, the live birth rate was 14.3 percent, spontaneous abortion rate was 23.8 percent, and ectopic pregnancy rate was 2.4 percent. CONCLUSIONS: Microsurgical tubal anastomosis is a justifiable alternative to IVF-ET in women age 40 years or older.

Unipolar electrosurgery in operative laparoscopy. Capacitance as a potential source of injury.

OBJECTIVE: To determine whether capacitive "stray" currents that can be generated during unipolar laparoscopic electrosurgery are likely to cause unintentional organ injury. STUDY DESIGN: In a controlled laboratory setting, the passage of capacitive current across the insulated portion of unipolar, 5-mm laparoscopic instruments was assessed for its ability to cause damage to biologic tissues. RESULTS: Modulated (coagulating) current output at power settings as low as 20-25 W led to apparent passage of current across the insulated portion of some laparoscopic instruments with thin insulation. This was accompanied by thermal damage to biologic tissues and instrument insulation. CONCLUSION: Our findings can explain unintentional injury during unipolar electrosurgery. The risk of such injury can be reduced by surgeon awareness, low generator output power and use of instruments with ample insulation. Thin insulation is more likely to be encountered with disposable than with multiuse instruments.

Operative hysteroscopy: American Association of Gynecologic Laparoscopists' 1993 membership survey.

The 1993 American Association of Gynecologic Laparoscopists' membership survey on operative hysteroscopy had 713 respondents reporting 14,707 procedures. Directed biopsy and endometrial ablation were the most commonly reported. The majority of operative hysteroscopies were performed for a complaint of abnormal bleeding (78%). The most frequent reported complication was uterine perforation not requiring transfusion (14.2/1000 procedures). The rates of water intoxication and pulmonary edema stayed essentially unchanged from 1991: 2/1000 in 1993 compared with 1.4/1000 in 1991. No deaths were reported this year. The consistency in rates of procedures performed and complications within the three surveys conducted in 1988, 1991, and 1993 add credibility to the data from these retrospective studies.

Laparoscopic sterilization: American Association of Gynecologic Laparoscopists' 1993 membership survey.

The 1993 membership survey of the American Association of Gynecologic Laparoscopists received 938 responses, or 13% of the membership. The surgeons reported performing 22,966 sterilizations and 36,482 diagnostic procedures. The distribution of sterilization techniques has remained stable since 1985. Complication rates associated with diagnostic procedures remain consistently higher than those with sterilizations. One death was reported from sterilization, none for diagnostic procedures.

Operative laparoscopy: American Association of Gynecologic Laparoscopists, 1993 membership survey.

The American Association of Gynecologic Laparoscopists' 1993 membership survey on operative laparoscopy had 1205 respondents reporting 80,031 procedures. Diagnostic laparoscopy remains the most common procedure, followed by adhesiolysis and laparoscopically assisted vaginal hysterectomy. This survey was particularly designed to chronicle the rate of complications as increasingly complex laparoscopic procedures are performed.

Preoperative sonographic evaluation and laparoscopic management of persistent adnexal masses: a 1994 review.

Carcinoma of the ovary is a frightening disease because it is a major cause of death due to cancer in women and is the leading cause of deaths from gynecologic malignancies. The disease is associated with a common clinical problem: persistent adnexal masses, most of which are benign. Operative laparoscopy has become an increasingly attractive way of diagnosing and removing adnexal masses. The practicing general gynecologist thus faces two new dilemmas: not to miss an early ovarian cancer or manage an unsuspected one to the patient's detriment, and not to perform extensive major surgery for adnexal masses, most of which can be handled laparoscopically. Fortunately, pertinent data exist on which the resolution of these dilemmas may be based.

Laparoscopic capacitance: a mystery measured. Experiments in pigs with confirmation in the engineering laboratory.

OBJECTIVES: Our purpose was to determine whether capacitive currents induced in operative laparoscopes during endoscopic electrosurgery can cause unintentional injury and to measure these currents in the laboratory. STUDY DESIGN: In five anesthetized live pigs we tested whether capacitive currents generated in operative laparoscopes by unipolar instruments cause serosal injury. These currents were then measured in the clinical engineering laboratory. RESULTS: In the setting examined by us serosal injury by capacitive currents occurred only with high generator output power. In the laboratory the maximum power of these capacitive currents measured 2.5 W. CONCLUSIONS: Capacitive coupling between unipolar instruments and 10 mm operating laparoscopes requires relatively high generator output to cause serosal injury. Lower generator output settings may cause injury with electrosurgical generators capable of higher voltages than the units used in this study (Valleylab SSE2L and Force 2).

Operative laparoscopy. American Association of Gynecologic Laparoscopists 1991 membership survey.

The American Association of Gynecologic Laparoscopists 1991 membership survey on operative laparoscopy had a total of 878 respondents reporting 56,536 procedures, for a 1.5-fold increase over the number of procedures reported in 1988. The most frequent indication was pelvic pain (58% of procedures); next was infertility (42%). Laparoscopic management of ectopic pregnancy increased over twofold, from 1,914 cases in 1988 to 4,620 in 1991. As compared to the 1988 survey data, the rate of unintended laparotomy to manage hemorrhage, bowel or urinary tract injury may have increased, but the death rate remained low, 1.8 per 100,000 procedures.

Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey.

The 1991 American Association of Gynecologic Laparoscopists membership survey on operative hysteroscopy had a total of 630 respondents (almost double the 1988 number) who reported performing 17,298 procedures as compared to 7,293 in 1988. Directed biopsy and endometrial ablation were the procedures reported most commonly. Endometrial ablation increased fivefold since 1988, and myomectomy increased fourfold. The majority of operative hysteroscopies were performed for a complaint of abnormal bleeding (73%). The most frequently reported complication was uterine perforation not requiring transfusion (11 per 1,000 procedures). The rate of water intoxication or pulmonary edema dropped from 3.4/1,000 in 1988 to 1.4/1,000 in 1991. However, some serious complications (eight laparotomies for bowel injury, three CO2 embolisms and three deaths) were reported for 1991.

Laparoscopic sterilization. American Association of Gynecologic Laparoscopists 1991 membership survey.

The 1991 membership survey of the American Association of Gynecologic Laparoscopists indicated more laparoscopic procedures than had been reported in the last survey, in 1988. The respondents reported 30,480 sterilizations, 41,160 diagnostic laparoscopies and 8,015 hysteroscopies. The distribution of sterilization by method of tubal occlusion has remained stable since 1985. Complications from diagnostic laparoscopy remain consistently higher than from sterilization. This year the complication rate for diagnostic procedures was higher than in any other year since 1976 (4.9 per 1,000 cases). One death was reported after sterilization and one after diagnostic laparoscopy.

PIP: 1314 members of the American Association of Gynecologic Laparoscopists responded to a survey enumerating numbers and types of laparoscopic procedures performed in 1991. The survey is conducted every 3 years. Members reported 40,337 laparoscopic sterilizations, 66,887 diagnostic laparoscopies, and 8015 hysteroscopies. This is an increase in both types of laparoscopies compared with 1988. Most of the sterilizations were done by bipolar coagulation. The types of sterilization methods remained similar to those used in previous years. 79% used a closed abdominal approach. 78% always used general anesthesia, while 1% always used local anesthesia. The complication rate for diagnostic laparoscopy was 4.9/1000 up from 3.1% found in the last 2 surveys. The rate of ectopic pregnancy among sterilization failures was 66% for bipolar and 68% for unipolar coagulation, somewhat higher than that found for Pomeroy, band, and especially the clip method. 2 deaths were reported, 1 for sterilization and 1 for diagnostic laparoscopy. Although these data are not randomized, the consistency of the questions and the sampling base make them worthwhile.

Bladder and bowel injury after electrodesiccation with Kleppinger bipolar forceps. A clinicopathologic study.

To evaluate the extent of electrocoagulation damage in tissue undergoing bipolar desiccation, five mature female pigs were used as models of tissue and adjacent vital structures commonly encountered during operative laparoscopy. Electrocoagulation was performed on bowel mesentery, sidewall peritoneum, ureters, uterus, uterotubal junction and broad ligament; superficial bowel and bladder burns were treated. Kleppinger forceps were also used to coagulate various-sized arteries to determine hemostasis. Histopathologic analysis demonstrated no inflammation or tissue destruction beyond the desiccated area seen immediately after coagulation and no direct correlation between tissue thickness and spread of electrocoagulation. It also appears that blood vessel hemostasis can be achieved safely with Kleppinger forceps on vessels up to 3 mm in diameter.

Spontaneous vaginal expulsion of Hulka clips.

BACKGROUND: Laparoscopic Hulka clip application is a common method of outpatient sterilization in women. We present a patient who experienced spontaneous expulsion of two Hulka clips. CASE: A 21-year-old woman was seen 17 months after sterilization because of spontaneous, asymptomatic passage of two Hulka clips into the vagina. The passage of one clip went unnoticed by the patient. Radiographic studies confirmed the migration and absence of two Hulka clips previously placed on the left fallopian tube. CONCLUSION: In rare circumstances, Hulka clips can migrate from the abdominal cavity and be expelled spontaneously, possibly by transuterine passage. This migration may occur without the patient's knowledge.

Intrauterine pressure and fluid absorption during continuous flow hysteroscopy.

OBJECTIVES: Our objectives were to document the causes of fluid absorption during continuous flow hysteroscopy and to determine under which operative conditions fluid overload may occur. STUDY DESIGN: Fifteen patients underwent operative hysteroscopy with 2% ethanol solution for uterine distention. Absorption of fluid was measured by blood alcohol, sodium, osmolarity, and hematocrit. Intrauterine pressures were measured with an obstetric pressure catheter. RESULTS: Alcohol absorption was noted in one patient during a myoma resection. Two additional patients, not in the study, had fluid absorption after partial perforations of the uterus. Under normal operative conditions there were no changes in sodium, osmolarity, or hematocrit. Intrauterine pressures ranged from 45 to 75 mm Hg. Experimental pressures of greater than 200 mm Hg were not associated with fluid absorption. CONCLUSIONS: Intravasation of fluid may occur through open uterine venous channels with extensive resections and under low pressures in the presence of unrecognized perforations.

Management of ovarian masses. AAGL 1990 survey.

The American Association of Gynecologic Laparoscopists (AAGL) membership was surveyed on the use of laparoscopy in the management of persistent ovarian masses in 1990. A total of 13,739 laparoscopies were performed for this indication. Ninety-six percent of the respondents performed laparoscopy for this indication on premenopausal women only. Among respondents performing laparoscopy for suspected cancer, there was a 14% conversion rate to laparotomy, compared to 9% among those who performed direct laparotomies when cancer was suspected. An overall incidence of 4 per 1,000 cases of stage I ovarian cancer was found, and about 70% of women with persistent adnexal masses were managed by laparoscopy alone. The risks to women with cancer, as well as the benefits to those without, are discussed.

Gas and steam sterilization of assembled versus disassembled laparoscopic equipment. Microbiologic studies.

Current recommendations specify disassembly of most laparoscopic equipment prior to sterilization. Surgical technicians, however, are often unfamiliar with the proper assembly of laparoscopic instruments, resulting in possible patient injury from equipment malfunction. Therefore, we tested the hypothesis that disassembled laparoscopic equipment is sterilized more thoroughly than assembled equipment. We inoculated internal sites on laparoscopic instruments prior to assembly with bacterial spores resistant to ethylene oxide and steam sterilization. We also manually cleaned the equipment after inoculation prior to steam sterilization of both the assembled and disassembled instruments. The control instruments were stored at room temperature during test sterilization runs. No vegetative bacteria survived ethylene oxide or steam sterilization in assembled equipment, but despite a significant reduction, spore-forming bacteria could be cultured from the assembled equipment. If the instruments were washed before steam sterilization, there was similar spore clearance in the assembled and disassembled instruments, with both groups attaining a high level of disinfection. Our data suggest that disassembly, cleaning and proper assembly of equipment prior to sterilization present no more risk of infection transmission than does disassembly during prevacuum steam sterilization. The method provides properly assembled and functioning equipment at the time of surgery.